Commoditizing Pharmacy, Commoditizing Adherence

Ever since the groundbreaking work of Dr. J Lyle Bootman in 1997 there has been a wide array of literature documenting the impact of inappropriate prescription drug use on overall health care costs. One standard consensus in the literature is that prescription drugs are a valuable form of treatment that helps improve patient health. Failure to use these medications appropriately may cause the patient’s health to deteriorate, leading to the need for more costly forms of treatment such as hospitalizations or a visit to the emergency room.

To provide some quick background, for those who have followed academic research on adherence, there is an underlying theme that the appropriate use of medications requires health professionals such as pharmacists and physicians to play a greater role in promoting patient-centric care. A great rundown of the health reforms needed to promote adherence can be found in the report Thinking Outside the Pillbox by the New England Healthcare Institute. Despite this consensus, at the end of the day the policy proposals that gain ground will depend upon the social construction of “adherence” in how it is perceived and defined.

Express Scripts proposes five profiles of “non-adherence” in its Drug Trends Report. Meet Susan, age 67, who is one of the five profilees of non-adherence. Susan is labeled a “traditionalist” by Express Scripts, which means that she uses her retail pharmacy rather than a mail order pharmacy. According to Express Scripts, this is considered a form of “prescription drug waste.” As Susan states in the glossy public relations document:

“I know I should use Home Delivery, but I’m used to getting my prescriptions filled at the store. I don’t like filling out forms and before you know it, it’s too late and I need my refill right away.”

To put the quote in context it’s important to remember that Express Scripts owns a mail order pharmacy (which the PBM calls “Home Delivery”) that dispenses medications to its “covered lives.” It’s worth noting that PBM mail isn’t the only “Home Delivery.”Most independent community pharmacies offer the service free of charge within a few hours—not days or weeks as with mail order—of the patient’s request.

The PBM mail order pharmacy is in direct competition with independent community and chain pharmacies for dispensing prescription drugs, which means Express Scripts has a financial incentive to steer customers away from these rival pharmacies and towards its own mail order pharmacy. Often this is done by PBMs imposing a financial penalty on patients when they use a local community pharmacy over the company’s mail order pharmacy.

Now, Express Scripts is attempting to steer patients towards mail order through a public relations campaign that defines “prescription drug waste” as using any pharmacy not owned by the PBM. This so-called “waste” supposedly costs America $6 billion a year according to page 6 of the Express Scripts report.

By contrast, a study published not long ago in the Journal of the American Pharmacists Association by Mirixa (a for-profit subsidiary of NCPA) showed that community pharmacists can play a valuable role in helping patients gain the most from their prescription drugs through medication therapy management programs. Pharmacists review medication regimens to eliminate duplicative therapies, prevent adverse drug events by making sure the drugs used will not counteract one another, promote less expensive generics over more costly brand name drugs, and work with the patient to drive higher rates of adherence through consultations and patient education.

Such an appropriate understanding of adherence, prescription drug waste, and patient-centric care can lead to better health outcomes and lower drug costs. As the Mirixa study demonstrates, these professional services provided by community pharmacists were able to help patients reduce their prescription drug costs by an average of $35 a month ($420 a year). Secondly, the study demonstrates that it’s very difficult to achieve the same cost-savings when these services are provided by a pharmacist through a mail order pharmacy.

On the other hand, if PBMs such as Express Scripts have their way in defining “adherence” and “waste” the key to reform will be diminishing the role played by community pharmacists and other local health care professionals so that PBM bureaucrats will have greater proprietary influence in decisions about patients health care decisions.

Just as pharmacy groups need to make sure that the pharmacy profession doesn’t become commoditized, pharmacy groups owe it to patients to make sure that adherence doesn’t become commoditized either.

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